Experiences With Unionization Among General Surgery Resident Physicians, Faculty, and Staff

Key Points Question How do general surgery residents, faculty, and staff experience unionization? Findings In this qualitative study including 19 health care professionals and 3 focus groups of residents at unionized general surgery programs, labor unions provided a mechanism for resident voice and agency, particularly regarding financial benefits; however, unintended consequences included a paradoxical loss of benefits and flexibility as well as resident-faculty conflict. Active representation helped increase the relevance of unions to surgical residents. Meaning These findings suggest that voice and agency are essential components of resident wellness and can potentially be facilitated by resident labor unions with appropriate representation.


Introduction
Since the Industrial Revolution, labor unions have represented employees and facilitated collective bargaining, advocating for improved employment terms and conditions.Workplace protections that are now foundational to US society-the federal minimum wage, Social Security, Medicare, and the 5-day/40-hour workweek-are attributable to unionization. 1 In a union, employees pay dues to a third-party executive to negotiate on their behalf.The right of workers to form a union is protected by the federal National Labor Relations Act 2 and is enforced by the National Labor Relations Board (NLRB), an independent federal agency.The role of the National Labor Relations Act is multifaceted and includes union election oversight and investigation of complaints for labor rights violations. 3though federal law protects and regulates the steps to forming a union (Figure), the process can be contentious.
Resident physician labor unions first appeared in 1934, when residents organized around compensation and working conditions as the Interne Council of Greater New York. 4In 1999, the NLRB issued a pivotal decision that physician residents are employees for purposes of federal labor laws. 5Resident physician unions usually include all residents across an organization as the same bargaining unit as they share a "community of interest," regardless of medical specialty; residents must work together as a unified voice when negotiating via the union.Currently, an estimated 30 000 residents are unionized through the Committee of Interns and Residents, an affiliate of Service Employees International Union. 6,7Since 2020, the number of annual unionization movements has tripled, and an increasing number of programs are debating unionization. 6,8sident unionization continues to be hotly debated. 9,10Recent survey data demonstrate that unionized programs are more likely to offer a housing stipend and more weeks of vacation time, but resident burnout, job satisfaction, and impressions of the educational environment are similar between surgical residents in unionized and nonunionized programs. 11The reasons for this similarity

Figure. Step-by-Step Union Formation
Establish contact with a union organizer or form an independent union.
Union meetings are held.
Employees are asked to sign union cards.a The union and the employer enter contract negotiations.
If a contract is successfully negotiated, it will have a term length.The union and the employer will reenter negotiations as the contract nears expiration.
If the union and the employer are not able to reach a suitable contract, the employees have the right to strike.
The employer can voluntarily recognize a union when a majority of employees have signed cards.
Alternatively, when at least 30% of the bargaining unit sign cards, the employees can petition the NLRB to conduct an election.
If the union wins 50% plus 1 vote, then a union is formed.b NLRB indicates National Labor Relations Board.
a Union cards are usually valid for 12 months.
b Refers to 50% of those who participate in the election (ie, does not need to be 50% of those employed).

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Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff in wellness between unionized and nonunionized programs represent a gap in the literature.We therefore sought to describe experiences of residents, faculty (attending physicians), and staff (program administrators) with resident unionization using a qualitative approach.

Methods
This qualitative study was approved by the Northwestern University Institutional Review Board.
Participants provided verbal informed consent.The study followed the Standards for Reporting Qualitative Research (SRQR) reporting guideline.

Site Visits and Interviews
The Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) trial was a prospective cluster-randomized study of the impact of the learning environment on resident well-being. 12During the exploratory phase of the SECOND trial (between March 6, 2019, and March 12, 2020), 2-day site visits were performed at 15 general surgery programs.Site selection was previously described. 13ring the 15 site visits, 366 individual interviews and 27 focus groups were conducted with residents, faculty, and staff.Each 45-to 60-minute semistructured interview was conducted by a pair containing at least 1 surgeon or surgical resident.Interviews were structured around a conceptual framework of surgical resident well-being but allowed for flexibility to promote candid conversations, given the wide scope of wellness. 14Follow-up questions were based on the progression of the conversation and impressions of the program over the course of the site visit, allowing for an in-depth understanding of the program context.Interviews were recorded, transcribed, and deidentified.

Data Analysis
In our qualitative analysis, we identified unionization as an emergent theme.Lexical searches were performed to identify transcripts containing relevant content.The study team inductively constructed a codebook containing themes and subthemes.All transcripts were individually coded by dyads that included at least 1 surgeon and then were reconciled by consensus using a constant comparative approach in MAXQDA, version 2020 (VERBI Software GmbH). 15A secondary review of all data (by D.C.F., A.E.R., Y.-Y.H., and J.K.J.) confirmed that findings of the dyads were consistent.
Data analysis was performed from March 2019 to May 2023.

Results
We identified 22 transcripts with content relevant to unionization; 19 were individual interviews with residents (n = 10), faculty (n = 4), administrative staff (n = 1), a program director (n = 1), a department chair (n = 1), and designated institutional officials (DIOs) (n = 2) and 3 were from resident focus groups.Residents from all postgraduate years (PGYs) were represented, as were residents in their professional development years (hereinafter, research residents).All union-related interviews occurred at 2 programs: one that had recently unionized and another that had been unionized for decades.The following themes were represented in interviews from both institutions in our qualitative analysis: (1) surgical residents unionize for voice and agency, (2) union-negotiated benefits have varying levels of efficacy and relevance to surgical residents, and (3) unionization affects the educational environment.

Theme 1: Surgical Residents Unionize for Voice and Agency
Surgical residents articulated that surgical culture is a barrier to voice, and the high workload is a barrier to advocating for improving the learning environment.Unionization allowed residents to

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Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff reframe complaints and move into a proactive space of improving their working conditions, as noted by this PGY1 resident interviewee: It's a very surgical mentality to just plod through things and not complain.We have an [operating room] workroom where half the computers are always broken, there's never toner in the computer, paper runs out.If one person just said to someone, "Can you fix this problem?" it would be fixed.But everybody just is like, "Oh, the computer is broken again, there's no paper, [what a] hassle.Move somewhere else."The union is kind of like the stand-in for that inertia that we have in our habits of just dealing with stuff.
All parties thus described unions as a unique mechanism for residents to voice concerns (Table ), like this DIO: I think that [the union] provide[s] a communication mechanism that is not present in other places.

Theme 2: Union-Negotiated Benefits Have Varying Efficacy and/or Relevance to Surgical Residents
Residents and faculty both enumerated financial gains negotiated by the union.These were primarily achieved through increased salary, as described by a PGY5 resident: We are paid very well, which I would argue is a wellness thing.We're paid probably $10,000-$15,000 more than our closest neighbor.…Wehave great benefits in terms of our health

Table. Representative Quotes About Resident Unionization
Theme Quote (participant) Theme 1: surgical residents unionize for voice and agency "I think [resident unionization] was a good thing in many ways because we always wanted to help our residents.…Idon't think that they're compensated enough, and I think they work 2 full-time jobs no matter how you do it, right?It's 80 h, and…a very stressful period in their lives.So, we were really happy to have the union impose some things that people (the organization) would just have to come up with the money to do it."(faculty) Theme 2: union-negotiated benefits have varying efficacy and relevance to surgical residents "We are contractually guaranteed paid…maternity and paternity leave.…Sixweeks for a vaginal delivery, 8 for cesarean.…Paternityleave is 2 weeks.…Previouslythere was only a 4-day paternity leave.And we've kind of broadened out the term for primary caregiver and things like that."(PGY5 resident) "The union is saying, 'You get 4 weeks paid maternity in addition to your 4 weeks of vacation,' but…the American Board of Surgery doesn't allow that, so…what are you going to do?We have to follow ABS rules more than anything."(PGY4 resident) "There's this sentiment that everything needs to be standardized, so any benefits that surgery residents get, if the medicine residents don't get them, they're worried about a labor dispute, and so they're saying that we can't do party things."(PGY5 resident 1) "Like our kickball, and stuff is no longer going to be allowed to be paid for by the program.…Weused to get a better education stipend than the other programs, which is now being taken away, and more food money than some of the other programs, which is now being taken away."(PGY5 resident 2) "I guess maybe we should have cared more when this all happened."(PGY5 resident 1) "That's what it really comes down to, we had opportunities to be involved and didn't."(PGY5 resident 2) Theme 3: unionization affects the educational environment "There's been a significant uptick in union activity.…Mostunions started working very aggressively to demonstrate value to their members, and the way you have to demonstrate value is showing that…the employer is doing things that only the union can protect you from.…We had grievances filed at approximately a rate of 1 a month."(DIO) "So, it has a lot to do with who's leading it.Not necessarily from the resident's side, but…because it's an independent organization, they hire essentially an executive to run it.And the person that's in that seat now is actually out of the [manufacturing] industry, which, as you can imagine, brings a culture of conflict and persecution to it a little bit.So, it's like: grievance, grievance, grievance, grievance.Everything is viewed from a conflict lens, and so literally there was a point where this person had 200 grievances filed against the GME office and the hospital."(program director) "And they've been largely overreaching lately where they're trying to insinuate themselves into basically academic issues about our residents' performance.Basically, it's turning into a little bit of the nursing union concept, where it's, 'You cannot fire me.No matter what I do, you can't possibly fire me because I've got the union rep right next to me.'" (program director) "We have actively worked around the issues of academic due process with this union because…they challenged the program director's authority and responsibility for signing off on competency at the end of training.They said that if there's academic discipline that results in an adverse outcome like probation or dismissal from a program, that those decisions needed to go to binding arbitration by someone who's not in the profession, which, of course, really flies in the face of what we try to do in training and what we're mandated to do." (DIO) "There's a lot of fear from the hospital.…They'reworried about labor disputes if somebody feels like a contract is violated."(senior resident, focus group PGY 3-5) Abbreviations: ABS, American Board of Surgery; DIO, designated institutional official; GME, graduate medical education; PGY, postgraduate year.Although financial benefits were universally appreciated, surgical residents often found other unionnegotiated benefits to be irrelevant or inaccessible to them.In both programs, surgical residents reported that they could not utilize union-negotiated time-off provisions: they could not take full parental leave without extending their training due to American Board of Surgery requirements (Table ), they could not take guaranteed holidays because there was inadequate clinical coverage, and they did not use preventive care time because surgical culture prizes self-sacrifice.One PGY5 resident stated the following:

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Our contract guarantees us 6 hours of preventive care, but none of us collect on that because we're afraid to collect on it.…Maybeafraid isn't the right word, but you just don't look dedicated.
Moreover, unions create rules and regulations to enforce uniformity across programs, which could result in 2 types of loss.The first was a loss of previously established benefits (presumably because other, less well-funded departments could not match the resources of surgical departments), as indicated by a faculty member: We are not going to be able to offer anything that is over and above what the contract specifies.…Weused to give them $1000 for academic accounts and things to spend, so, we're not able to give that money anymore.So, it has to be whatever everybody else gets, whatever gets negotiated.
The second was a loss of flexibility for the program to meet residents' individual needs, as noted by 2 PGY5 residents: We take pride in making the schedule in a way that's good for resident well-being.All of that work, to have the possibility that these random, new restrictions are going to be put on it, after we've spent a lot of time accommodating every request we've ever gotten for the schedules.
I get a little upset about this idea that Thanksgiving, Christmas, and New Years [are union holidays] because I don't celebrate Christmas, but my Hindu holidays, I don't have off.
The previous quote speaks to how standardization for the benefit of the majority may unintentionally result in exclusionary practices.
Residents acknowledged that lack of surgical representation within the union structure was a major reason that union-negotiated benefits were of limited utility to the surgical subspecialties (Table ).One PGY4 resident stated the following:

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Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff A lot of the potential benefits are realistically probably not going to be reaped by surgical subspecialties.…Admittedly,could we have been involved in it infinitely more than 99% of us have been?Yes.

Theme 3: Unionization Affects the Educational Environment
Educational leadership noted that because unions are a third party whose role is employee advocacy, they may amplify conflict to demonstrate value to their membership (Table ).Leaders perceived that union executives encouraged residents to engage in conflict rather than bring issues directly to their leaders to be solved collaboratively.In the words of a program director: Unfortunately, I think [the union] is a negative influencer on resident culture, because [the residents] sort of hear from this person, like, 'You let me know the first sign of trouble-I'll take care of it.'And you know, it creates this suspicion, this mistrust that everybody's out to get them.…That'sa unique challenge we have here…that independent union stance that tends to inject conflict into it.…Sothat is a challenge, even for me, in a program that functions in a pretty healthy way because residents, if they're having an issue, there's probably a 2-to-1 chance they're going to go to the union before they go to me.…That's not always the best way to solve problems; it tends to make problems much bigger than they needed to be.
This framing of the union as the sole recourse for residents against an unsupportive administration was perceived to be further influenced by hired union executives' prior experiences in other industries (Table ).
When surgical residents participated within the union, educational leadership complimented these resident leaders for their ability to mediate conflict between the union and the institution.Two interviewees-the first a program director, the second a DIO-offered the following: One of our residents is…the [leader] of the [union] this year.And she's a very rational person that understands which fights are worth having and which ones aren't.
We had two pretty contentious [resident leaders] of the union.…The[resident leaders] of the union are elected by the house officers, and the current [resident leader] is actually a general surgeon, and since she has taken the post, we've only had 1 grievance, which was subsequently dropped by them.
As reported by faculty, administrators, and residents, conflict extended beyond specific union-filed grievances to affect relationships between residents and their faculty.Two more interviewees-the first a PGY5 resident, the second a DIO-stated the following: It violates the educational contract we have with our faculty.
Unfortunately, the process of unionizing puts us in an adversarial relationship with residents.
That's just the nature of the beast.…Thenature of unionizing is not all that compatible with mentoring and thinking about the members of the union as learners.
Conflicts around clinical educational assessments were particularly contentious.Residents described a sense of employment protection from having hired union executives participate in deliberations about remediation, probation, or dismissal; they perceived that this process ensured fair due process, as reflected by a PGY5 resident: If there's…disciplinary action, I've heard from people that the union really sticks up for you, and so I think…we're mostly very pro-union.

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Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff However, educational leadership felt that because union executives are nonclinicians, their involvement in discussions of academic advancement was inappropriate and hindered necessary remediation efforts, ultimately affecting training quality and patient safety (Table ).One DIO described this as follows: Across the country, I think a number of DIOs have raised a concern that unions, which are organized around employment issues, are now trying to make forays into academic issues.And I will tell you that the institutions feel pretty strongly…that the programs actually have jurisdiction over who advances, who graduates.…Theprograms…the institutions feel that they should have sole direction over what patient duties are assigned.…Wefeel that we own the public trust, which is not to put people in positions of unsupervised activity, whether it be graduating them or advancing them, that we…don't feel is appropriate.…Weprotect the public.
We're paid for that, that's what we do: we try to graduate safe, competent…physicians.
Aside from its effect on resident-faculty relationships, unionization was described as having This quote speaks to the evolution in negotiations as the union at an institution matures and the potential of union-led advocacy to benefit patient care as well as resident working conditions.

Discussion
This study of the experience of resident unionization at 2 institutions highlights the important role of voice (an expression of a wish, choice, or opinion) and agency (the capacity to act or exert power and influence) in resident wellness.Voice and agency are critical to employee engagement and wellbeing across work environments. 167][18][19] Bongiovanni et al, 20 in a qualitative study of residents who left general surgery, identified lack of voice as a major reason for attrition.Our data provide insight into how leaders, departments, and institutions may effectively advocate on behalf of their residents and, more specifically, how they may do so within the context of resident unionization.
Freeman and Medoff 21 described 2 mechanisms of combating workplace problems: exit or voice.However, because residency is largely designed to be started and completed within the same institution, residents have limited options for exit; indeed, only 20% of general surgery residents who leave their residency program switch to another general surgery program. 22Because residents depend on their employer to provide the training they need to progress in their careers, 23 concerns about the lack of exit options may precipitate reservations about expressing voice.In this study, residents spoke about how unionization provided a mechanism for raising and addressing issues.
Such representation has been argued to provide an avenue for promoting meaning in work and life. 24terviewees particularly valued their union-negotiated financial benefits.The importance of this benefit cannot be overstated, particularly in the context of stagnant resident wages relative to inflation 25,26 ; financial security ranks second in Maslow's hierarchy of needs.Notably, no resident mentioned the cost of union dues.In our prior study of resident unions, using the American Medical Association FRIEDA database, we found that resident salaries were similar between unionized and

JAMA Network Open | Surgery
Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff In this qualitative study including 19 health care professionals and 3 focus groups of residents at unionized general surgery programs, labor unions provided a mechanism for resident voice and agency, particularly regarding financial benefits; however, unintended consequences included a paradoxical loss of benefits and flexibility as well as resident-faculty conflict.Active representation helped increase the relevance of unions to surgical residents.Meaning These findings suggest that voice and agency are essential components of resident wellness and can potentially be facilitated by resident labor unions with appropriate representation.
Experiences With Unionization Among Surgical Resident Physicians, Faculty, and Staff JAMA Network Open.2024;7(7):e2421676.doi:10.1001/jamanetworkopen.2024.21676(Reprinted) July 17, 2024 4/11 Downloaded from jamanetwork.comby guest on 08/05/2024 positively affected the clinical and educational environment by advocating for increased support staffing.As a program director noted: And through the years, [the union has] served different roles.The fundamental purpose for its existence is to bargain collectively with the hospital every 3 years or so.[Earlier,] it was mostly around what your salary's going to be, making sure you have parking, making sure you have meal tickets, that sort of mechanistic stuff.And it changed a little bit after that-[the union] worries more about getting the hospital to invest in better support resources, like we need more radiology techs at night or need more phlebotomy teams.So, it's still very constructive.